Mmmmmm....

I really, really meant to do the seven by seven that other bloggers have tagged me with tonight. I swear I did.

But I got distracted with making biriyani.

Oh, my God. I make some kick-ass biriyani. I do.

You can taste the ghee in the plain rice. The yogurt-marinated chicken is perfect and tender. The onions are burnt to just the right burnt-onion taste, and the potatoes are brown.

I think I'll go Google "Sindhil Ramamurthy" and "John Abraham" (my friend Deepa says, "And he has a name you can pronounce!!") now.

Mmmmm. Biriyani.

In fact, if you don't bite into one of those *$(*(*$#@&* dried tamarinds contained in the Bombay Biriyani mix, it's perfect. PERFECT, I tell you.

Mmmmm.

From the "Oh, Shit, I Forgot" Files...

Check this out.

I have no clue how long Janet has been blogging, or how long she's been a nurse. What I *do* know is this: if you want to model your nursing blog on somebody, model it on Janet's. She writes in a simple, straightforward style with understandable language and heart-wrenching simplicity. It's fast becoming my new favorite, along with Sid's.

You know it's time for a glass of wine when...

...a memo describing an upcoming change in hospital policy gets you so angry that you send a snarky, venting email with scarcely a word under three syllables off to your manager, ranting about how un-Einsteinian Upper Manglement is.

And then, even though you prefaced it with the disclaimer that it was venting and snarking and nothing more, your manager finds that it so perfectly describes the mood of The Lowly Worker that she forwards it.

To everybody.

Everybody, that is, except the president. Who will probably hear about it anyhow, within a matter of days.

Good thing I used nice, big words and phrases I can look back on with pride, such as "(the) headlong gallop down this precipitous slope to mediocrity" and "the breathless pursuit of the lowest common denominator."

The memory will keep me warm in the cardboard box I'm sure I'll be living in starting Monday.

Best blog.

Read this. As usual, I'm late on the boat, but I just spent an hour reading Dr. Sid. Can't wait to get back to him.

Minor Procedural Gripes.

If you are a doctor, please, *please* do not use the nurses' computers when the doctors' computers are entirely unoccupied. And if you do, please, for your own sake, don't grouse when I say "Excuse me, please" politely and make a long arm to reach for my charting. Even if you are an attending--and I'm talking to you, Doctor Wire-Rimmed Oncologist--I will slit your belly and hold your smoking entrails up before your dying eyes if you refer to me at work as a bitch. Outside of work I'll just kick your ass.

Just so's we understand each other. That memo? Got sent. Have a nice Monday, doc.

Jack And Jill V-Cut Spicy Barbecue Flavor Potato Chips should either be available free of charge in the continental United States or banned as a controlled substance. No more importing them from the Phillipines, people. If I can only get my Spicy Barbecue Flavor Chip Fix twice a year, I get grumpy.

Which reminds me: Mom, Dad, why did you have to raise me so that my comfort foods are refritos and blackberries? Why couldn't I have been a *normal* kid?

If you're a resident, please keep in mind one simple thing: I work at one hospital. You work at three, in rotation. Therefore, I know the rules at my hospital better than you do. Your attempt to bully me into breaking the rules at my hospital because you're too lazy to come out on a Saturday will result in your attending being...unhappy. The less said about the sequelae, the better.

If you're a nursing student, please, *please* do not look at me like I've just grown a third head and am about to take a bite out of you with it. I promise, I want you to succeed. I will go to a lot of trouble to make sure you get a good clinical experience. Just don't stammer and go silent when I say "Hello". I like you. I really like you.

Note to other nurses: If a patient is deaf or does not speak English, yelling will not make them suddenly un-deaf or fluent. A lot can be accomplished with smiles and nods and an interpreter.

I don't care if you drive a Prius: don't go 45 in the passing lane.

I'm off to my usual Sunday comfort-food and "Extreme Makeover: Home Edition" fest. And I hate the producers, actors, and director of "Grey's Stupid Whiny Anatomy" for making me curious about what happens between Meredith and Doctor McFacelift in the season premiere. I hate them. Hate them. And yet....I wonder.

Burke is much, much hotter, by the way. But Gregory House? Hottest of all.

He can almost kill me five times in forty-two minutes any time.

Quick note:

In case I should disappear for a while, it's not because I'm busy strangling hammer-wielding intruders or because I've fallen victim to some strange bug. The provider of Innernetwebwideness that I use has decided to stop providing a hookup, so I've had to go with a Large Corporate Provider. The LCP says my Innernetness will be accessible by 10/5, and I don't know how long the old line will stay up.

That is all. Return to your regularly scheduled more important things.

Results of a recent study show...

...that among nurses who watched a cumulative 4.5 hours of "Grey's Anatomy", 100% repeated, over and over and over during the course of the show, "I AM SO GLAD I DO NOT WORK WITH YOU PEOPLE."

Ten percent of respondents also volunteered the information that they would rather enoculate themselves bilaterally with a rusty runcible spoon than watch the Season 3 premiere.

Thank you. That is all.

So you're a nurse. Now what?

I got a request for a post about role confusion (that awful feeling that comes from being a new nurse), and it sounded like a good idea. The transition from student to preceptored nurse isn't as hard as you'd think; you still have to show up on time for various classes and lectures, you still have somebody following you around, you still feel like there's some leeway for mistakes.

Coming off a preceptorship, though, is a whole 'nother deal. All of a sudden, you're a Nurse. But you don't feel like one; instead, you feel like some shmuck that's been picked up off the street and dumped into scrubs. Things seem really, really hard--even simple things, like a focused assessment of a patient.

Here's what I learned when I was a new, nervous nurse, then:

1. You will not kill anybody.

Unless you do something spectacularly idiotic, which is very very very rare, you will not kill anyone. You have people looking out for you--this is true throughout your nursing career--and every action you're expected to take has gone through a number of people more experienced than you.

2. Remember the First Rule Of Nursing: If you have to jack with it, it's wrong.

That one little rule will save you every time. Hospital and clinic work has been streamlined and perfected over the years so that it's practically tired-new-nurse proof. Therefore, if you find yourself having to improvise or make things up to get something done, take a good look at what you're doing. The likelihood is that you're either doing the right thing wrong or the wrong thing altogether.

3. If you do screw up, report it immediately.

Nobody is going to fire you, yell at you, or make you feel like an idiot. (Chances are, you'll do that last one to yourself.) Everybody, even Super Nurse Extraordinaire, makes mistakes every day. That's why we have procedures in place to, say, double-check settings on pumps and so on. If you screw up, it's important to report it so you can have help figuring out *why* you screwed up, and how to manage the situation in the future.

4. Ask questions.

Everybody asks questions, including Super Nurse Extraordinaire. Most of us ask them constantly. We all double-check each other, help each other out with weird titrations, give second opinions on whether or not that patient is more or less gorked than the day before. Your colleagues are part of a team that includes doctors and other nurses and X-ray techs and respiratory folks. Ask 'em all questions. If anybody tries to make you feel stupid, respond politely and be effusively thankful. That'll embarrass them no end.

5. Honesty is the best policy.

If a patient asks you how long you've been a nurse, *be honest*. You're not fooling anybody. If you don't know something, *say so*, then vow to find out the answer. This, too, happens every day.

6. But don't volunteer information.

I say this not because patients are stupid or mean. I say this because if you give somebody too much information, it can be truly overwhelming. Stick to answering the questions you get asked, like "How long until I can shampoo?" or "When will my stitches come out?" Don't go into a dissertation on possible side effects that only occur in 0.1% of the population. This is a lesson I learned the hard, hard way.

7. Fake it.

Act confident and friendly, even if fear makes you want to throw up and pass out. Eventually you will feel confident and friendly. In the meantime, nobody else will have to deal with your vomit or prone body.

8. Going home in tears is not necessarily a bad sign.

You will be so overwhelmed, stressed out, and exhausted that you will occasionally sag against the wall of the elevator and weep. This is a normal part of the stress that comes with being a nurse. It becomes less frequent as you learn more. It's okay. Here, have a cookie.

9. People will occasionally do mean things or get inappropriate with you.

Wackos can smell a new nurse. I got odd suggestions, inappropriate physical contact, and outright bullying more in the first six months I was a nurse than I have in the following three-and-a-half years. Be patient. Eventually you will develop that Nurse Callus that allows you to see the loonies coming and deal with them. In the meantime, lean on your charge nurse and your colleagues to help you get out of rooms unscathed. And if you're getting consistently shitty assignments with a higher-than-normal proportion of weirdos, complain. It's not fair to saddle the newbie with all of the nutjobs.

10. You will, someday, feel like a nurse.

I remember when that happened. I had had a day during which I had made only a couple of minor mistakes, caught them before they'd done any harm, and had caught a problem before it developed into something severe. Further, I had had time to pee and eat and actually take *time* with my patients.

That didn't happen until I'd been a nurse for more than a year--maybe even more than two. I don't remember the exact date, but I do remember the feeling. It was though I had finally gotten the hang of swimming with the current.

This will happen to you, too. I can't stress that strongly enough. Nursing is a constant learning process. You feel off-balance every day of your professional life, and there's always something you don't know. Nevertheless, there will come a day when you realize that you're looking ahead of what's immediately in front of you, and when care plans finally begin to make sense. You'll build on skills you already have when it comes time to learn something new. Yeah, you'll fuck up royally the next day and go home in tears, but you'll have had that one day when you can say, honestly, 'I am a nurse.'

And then, a few years down the line, you'll be chatting with a notoriously hardassed doctor and apologize for doing something dumb, like calling her at 3 am, and she'll say, "Y'know, if it comes from a good nurse, I don't really mind it when I get called at 3 am." And she'll smile, and you'll know that Good Nurse = You.

A tribute to ED nurses....

PORTLAND, Oregon (AP) -- A nurse returning from work discovered an intruder armed with a hammer in her home and strangled him with her bare hands, police said.

Susan Kuhnhausen, 51, ran to a neighbor's house after the confrontation Wednesday night. Police found the body of Edward Dalton Haffey 59, a convicted felon with a long police record.

Police said there was no obvious sign of forced entry at the house when Kuhnhausen, an emergency room nurse at Providence Portland Medical Center, got home from work shortly after 6 p.m.

Under Oregon law people can use reasonable deadly force when defending themselves against an intruder or burglar in their homes. Kuhnhausen was treated and released for minor injuries at Providence.

Haffey, about 5-foot-9 and 180 pounds, had convictions including conspiracy to commit aggravated murder, robbery, drug charges and possession of burglary tools. Neighbors said Kuhnhausen's size -- 5-foot-7 and 260 pounds -- may have given her an advantage.

"Everyone that I've talked to says 'Hurray for Susan,' said neighbor Annie Warnock, who called 911.

"You didn't need to calm her. She's an emergency room nurse. She's used to dealing with crisis."

Hat tip: Grunt Doc

Read this.

Thou Art With Us.

The Bowels of the Hospital

In most hospitals in the US, poop is the nurses' purview.

Shit is our shingle.

Bowel movements are our raison d'etre.

It's an ugly fact of life, but it's true: if you have a patient who's undergone brain/cardiac/leg/facial surgery (anything, practically, short of surgery for an intestinal obstruction or ileus), it is your responsibility as a nurse to make sure that they're regularly moving their bowels. Pooping on schedule, as it were. Dumping a load like clockwork.

That sounds easier, to the lay person, than it actually is. See, we hand out narcotics like candy (what? They're not candy?), and narcotics slow the passage of feces (or "stuff", in the medical terminology) through the bowel. Stuff that takes a long time to pass through the lower intestine becomes dried out as more and more water is absorbed. Sometimes the lower intestine itself gets lazy, and then you have the dual problem of dry Stuff and Lazy Bowel.

In short, we deal with a lot of constipated patients a lot of the time.

Normally, protocols demand that a patient move (or "open", for our friends in the UK and Oz) their bowels no less than once every 48 hours. After certain surgeries, like an open aneurysm clipping, once every 24 is preferred, as to avoid straining and possible increase in thoracic and intracerebral pressure. I thought it might be nice and amusing and edifying to go over the ways in which we manage that. Note two things: that I'm on my second beer, or else I'd *never* be typing about poop, and that these hints and tips do not apply to spinal-cord-injury patients, who are a whole 'nother ball of wax. Or dung.

Stuff Softeners: The First Line of Defecation

Docusate sodium and docusate calcium fall into this category. They're over-the-counter medications that draw water into the bowel in small amounts, allowing Stuff to remain soft, pliable, and evacuate-able in the normal person. Note that overdosing a patient on Stuff Softeners is a bad idea, as the Stuff will become so soft that it either just sits there, or turns into diarrhea. Stuff Softeners won't work for a patient who has pre-existing problems with constipation or who's badly impacted. Don't waste your time.

Milk of Magnesia: The MOM of All Remedies

MOM is technically a saline laxative. Saline laxatives work by drawing water into the bowel, following the principle that heavily saline solutions on one side of a membrane will attract water to balance their concentration. (Am I reminding you of chemistry yet?) MOM works best, I've found, on an empty stomach, two hours before any medications, and when followed by sixteen ounces of water. It's good for the moderately-constipated patient with no huge health problems (the usual neurosurgery candidate, in other words).

Prune Juice: Grandma's Remedy or Old Wives' Tale?

I've never had a lot of success with prune juice, even warmed, unless it's with people who've been using it for years as a laxative. Apparently it contains some chemical that causes the bowel to move. The downside is that it won't work with most folks. The upside is that it's the Drink of A Warrior, according to Whorf (/geek).

Stimulants: Use At Your Peril

Bisacodyl and Bisacodyl Uniserts, also known as Dulcolax or Correctol (tablets and suppositories) are stimulant laxatives, as is senna (Sennakot). Both will send your patient into low-earth orbit if they're not terribly backed up, and will cause hemorrhoids if they are. I use the pills as a last resort and the suppositories as a next-to-last resort. The major drawback of stimulant laxatives is cramping; the secondary drawback is major, major pooping.

Magnesium Citrate: When Your Best Just Isn't Good Enough

Give a patient a glass full of ice-cold cherry flavored mag citrate and a straw, tell 'em to drink it fast, and then...stand back. You'll hear their bowel sounds from the doorway. Mag citrate is a saline laxative--the difference between it and milk of mag is volume. More volume equals more water equals more...well, you get the idea. I love mag citrate, though it should be used with extreme caution in people with electrolyte imbalances. It'll cure what ails you, for sure.

Back Door Remedies: When You Get Stuck

Enemas are often the nurse's best friend. You can have plain enemas (tap water or saline, warmed, with or without a little liquid soap added), weird enemas (SMOG or bubblegum or milk and molasses), or dreaded enemas (The Dreaded Triple-H).

Plain enemas are used most often as cleansing treatments. They help the patient get rid of whatever's up there, plus, they leave the intestine relatively clean in the process. My personal favorite is 750 ml normal saline warmed in a graduated cylinder in the microwave, with the remaining room-temperature saline added until the temperature is comfortable. (Note: it should feel slightly warm on your wrist.) I'm not crazy about soap; it seems too turn-of-the-century to me, though there is plenty of evidence that the irritant nature of castille soap helps with evacuation. Personally, a liter of warm saline in yer poop chute seems like irritant enough to me.

SMOG, bubblegum, and...molasses? You're Kidding, Right?

No, children, I am not.

SMOG stands for saline, milk of mag, and glycerine. Bubblegum enemas are saline with some liquid docusate sodium added. Both are low-volume enemas that depend on the chemical ingredients for Stuff softening and stimulation. They're prescribed, in my experience, by well-meaning residents who have no clue what they're up against. The experienced nurse goes for...

Milk And Molasses: An Unlikely But Effective Combination

250 ml of whole milk (or thereabouts), mixed with an equal amount of ordinary molasses, warmed, works a treat. The molasses draws water into the bowel while the milk greases the works, as it were. Results are fast and gratifying (for the patient). We keep a gallon jug of molasses in the clean utility room and go through it in about three weeks. This, along with the half prune juice, half mag citrate cocktail, should be in every nurse's arsenal.

The Triple-H: High, Hot, and a Hell of a Lot

We're talking tap water or saline (my preference) in quantities of a liter. Or more. The outcome should be obvious. I only use these in extremely constipated patients with attitude problems.

Disimpaction: A Manual Manual

Disimpaction is unpleasant for both nurse and patient. Probably less pleasant for the patient, but it's close. We do manual (sticking fingers where fingers normally don't go) disimpaction when a patient has a rectum and lower bowel full of hard, dried feces that they can't excrete. It *hurts*. Using lots and lots of lubricant and a gentle touch will help, but you can't get around the fact that you're ouching somebody who's already ouched out.

It should be avoided at all costs, and not just because it lacks dignity. You can easily traumatize delicate tissue while doing a manual disimpaction. And, frankly, if a patient gets *that* impacted while in the hospital, somebody isn't doing their job. Even a mineral oil enema to loosen things up and grease them along is preferable to the trauma of disimpaction. You can always do a cleansing enema afterwards.

And there, children, you have it. Probably more than you wanted to know, but at least a bit helpful for the new nurse or student. Enjoy your day, eat your salad, and for heaven's sake, don't let your patient go more than 36 hours without a tour of the porcelain empire.

Wahoo! Change of Shift is up...

...and I'll be happy if I can ever stop typing that as "Change of Shirt". *sigh*

Right here.